SonoCase: Pregnant pt with 1st trimester vaginal bleeding/pelvic pain in @EPMonthly #FOAMed

Drs. Teresa Wu and Brady Pregerson bring another engaging discussion to the great question: Should someone with a prior vaginal ultrasound for pregnancy evaluation get another one with repeat visits to the emergency department? Well, as they will describe, it may not be needed, but it sure does help patient satisfaction (and especially relief if they are concerned about their baby). So, if you do, it is all about your ability to interpret the images correctly. They identify some great vaginal/pelvic ultrasound pearls and pitfalls to keep in mind in the end of the following case:

“There are twenty-eight patients in the waiting room with the longest waiting 4 hours. The queue for CT scans is over 2 hours and the one for ultrasounds is even longer; a staggering 4 hours, plus another hour to get results. Lots of people are frustrated. Your next two patients are both pregnant females in their first trimester with vaginal bleeding. As you perform your H & P, you encounter more similarities between the two. Both have midline crampy pain like a period, with no fever, no vomiting, and no syncope. Both recently had ultrasounds done, one in your ED 3 days ago, and one with her obstetrician four days ago. You know why they are here. One reason – they want to see if their baby still has a heartbeat. You also know that repeating the ultrasound is not really medically indicated using the strict sense of the word. Sure it’s reasonable, even customary, but will it change management tonight? Can’t they just see their OB tomorrow? Is it really the right way to practice medicine to clog up your department even worse while simultaneously adding one more straw to the camel carrying the national healthcare budget? Who are you going to listen to? Press and Ganey? Barack Obama? Your conscience? What will the parents think and how will they react if you tell them, “Sorry, we can’t do an ultrasound tonight. You have to go home and make an appointment tomorrow to see your doctor.”?

The following ultrasound images are obtained in each patient:

Screen Shot 2013-07-03 at 6.39.47 PM Screen Shot 2013-07-03 at 6.40.19 PM

Do you know how to interpret them? Read more on vaginal ultrasound and their great pearls and pitfalls here.

Great pearls to keep in mind:

gestational sac only – early intrauterine pregnancy (IUP) or pseudosac of an ectopic pregnancy

gestational sac with yolks sac or fetal pole – early IUP

gestational sac with fetal pole and cardiac activity – LIVE IUP

For a review on the beta hcg (and if we can /should use ti anymore) and early pregnancy evaluation with ultrasound, go here.


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